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Accepted Manuscript

Music is an effective intervention for the management of pain: An umbrella review

Juan Sebastian Martin-Saavedra, Laura Daniela Vergara-Mendez, Claudia Talero- Gutiérrez

Accepted Manuscript Music is an effective intervention for the management of pain: An umbrella review Juan10.1016/j.ctcp.2018.06.003 Reference: CTCP 879 To appear in: Complementary Therapies in Clinical Practice Received Date: 20 March 2018 Revised Date: 30 May 2018 Accepted Date: 5 June 2018 Please cite this article as: Martin-Saavedra JS, Vergara-Mendez LD, Talero-Gutiérrez C, Music is an effective intervention for the management of pain: An umbrella review, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.06.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. " id="pdf-obj-0-8" src="pdf-obj-0-8.jpg">





CTCP 879

To appear in:

Complementary Therapies in Clinical Practice

Received Date: 20 March 2018

Revised Date:

30 May 2018

Accepted Date: 5 June 2018

Please cite this article as: Martin-Saavedra JS, Vergara-Mendez LD, Talero-Gutiérrez C, Music is an effective intervention for the management of pain: An umbrella review, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.06.003.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.


TITLE: Music is an effective intervention for the management of pain: An umbrella review SHOR TITLE: Music for the management of pain


Juan Sebastian Martin-Saavedra, M.D. (Corresponding author).


Affiliations: Research assistant of the Clinical Research Group. Escuela de Medicina y


Ciencias de la Salud. Universidad del Rosario, Bogotá D.C., Colombia.

Address: Carrera 24 # 63c-69

Contact: + 57 1 297 0200 ext 3426

Laura Daniela Vergara-Mendez, M.D.


Affiliations: Pediatrics Resident Escuela de Medicina y Ciencias de la Salud. Neuroscience

Research Group NeURos. Universidad del Rosario, Bogotá D.C., Colombia.

Claudia Talero-Gutiérrez, M.D.


Affiliations: Main professor and Coordinator of the Neuroscience Unit, Nueroscience

Resarch Group NeURos. Escuela de Medicina y Ciencias de la Salud. Neuroscience

Research Group NeURos. Universidad del Rosario, Bogotá D.C., Colombia.


TITLE: Music is an effective intervention for the management of pain: An umbrella review SHORT TITLE: Music for the management of pain



Aim: This study aims to analyze and describe the effects of music listening in the management of pain in adult patients, as reported in systematic reviews and meta-analysis.

Methods: A search of articles published between 2004 and 2017 was conducted on Pubmed,

ScienceDirect, Scopus, SCIELO, SpringerLink, Global Health Library, Cochrane, EMBASE and

LILACS. Search, quality assessment, and data extraction was done independently by two researchers.

Results: Most of reviews found a significant effect of music on pain. All analyses had a high

heterogeneity, and only acute pain and music delivered under general anesthesia had moderate

heterogeneity. No differences were found when music was chosen by the patient. Music type and its

characteristics are scantly described and in terms that lack validity.

Conclusions: More focused trials and reviews, objective language for music, and trials with music chosen

by its characteristics are required.


Music; Music Therapy; Pain; Pain Relief; Music characteristics; Review.




The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and

emotional experience associated to an actual or potential tissue damage (1). Pain is one of the main symptoms and burdens in clinical practice (2), and the complexity of its management has motivated the study of complementary therapies (defined as “health care approaches with a history of use or origins

outside of mainstream medicine”) (3).

The American Music Therapy Association has defined music therapy as the use of music by a certified

professional (defined as an individual who has completed an approved music therapy program) for the

accomplishment of specific therapeutic goals (4, 5). Music therapy can be active (the patient participates

through singing or playing an instrument during the intervention) or passive (the patient only listens to

music) (4-6). Music listening involves different areas related to pain modulation like periaqueductal gray

matter, spinal networks, primary somatosensorial cortex, cingulate cortex, and others (7-12). Additionally,

music modifies brain activity during pain stimulation (13), supporting its analgesic effect. As a result,

listening to music has been proposed as a complementary therapy for pain (14).

The present study’s objective is to summarize the evidence on the effects of music listening as a

complementary therapy in the management of pain of adult patients, according to what has been reported

in systematic reviews and meta-analyses in the last twelve years. Particularly, this paper aims to analyze

the effect of music on different kinds of pain, the description and reporting of the music listening

intervention, and if any conclusions on the type of music or music characteristics have been reached.



  • 2.1 Study design

The main search protocol was done with the following pre-defined search criteria: controlled trials,

systematic literature review or meta-analysis, published from 2004 to July 2017 in Spanish, English,

French, Italian and German. Two studies were conducted, a systematic review and meta-analysis of

randomized clinical trials, and this umbrella review. Umbrella reviews (also known as overview of

reviews) are a recently developed method to summarize, and analyze systematic reviews. This type of

review is based on a planed and structured comprehensive search, similar to traditional systematic

reviews, but it searches systematic reviews instead of clinical research (e.g. Clinical Trials). Currently, no

widely used guidelines exist to carry out this type of review. However, we followed the recommendations

of the PRISMA statement for search strategy design, and made use of the AMSTAR tool for quality

assessment. Another related issue is that it is a summary of summaries, so specific information may not be

described (15). As the main search protocol was designed with the PRISMA guidelines, the methodology

was adapted for Umbrella Reviews.

  • 2.2 Search strategy

The search was constructed based on the 2010 PRISMA statement (16). The MeSH terms music, pain and

music therapy; and the non-MeSH terms pain relief, music-supported therapy, instrumental music, slow

music, rapid music, music mode, pleasant music, unpleasant music, music tempo, music tonality, pitch

range music, and musical structural features were used. The search was performed on Pubmed, Scopus, SCIELO, SpringerLink, Global Health Library, Cochrane (through OVID), EMBASE, and for a broader search ScienceDirect and LILACS were also searched as they include gray literature. The search was refined by means of each search engine’s filters, if this functionality was unavailable, they were included


as additional search terms, as follows: (“music” AND “pain”) AND (“systematic review” OR “meta- analysis” OR “clinical trial”) AND adults.

  • 2.3 Duplicate search and study selection

JSMS and LDVM undertook continued surveillance of literature and results from the search were

imported to EndNote™ and duplicates were eliminated. JSMS and LDVM checked titles and abstracts to

eliminate all studies that weren’t clinical trials, systematic reviews or meta-analysis. Abstracts were then

reviewed, and studies were eliminated according to inclusion and exclusion criteria (see figure 1).

Systematic reviews, Cochrane reviews or meta-analyses of music interventions used for pain relief were

included in this review. Studies that did not evaluate music’s effect on pain, that only included studies

combining music with other therapies (e.g. Music and guided imagery), or that only included studies not

evaluating pain with a quantitative tool, were excluded.

  • 2.4 Quality assessment

JSMS and CTG assessed quality for all included articles independently using the Systematic Reviews and

Meta-analysis Notes for completion checklist (SIGN tool) (based on the AMSTAR checklist (17)). A third

author resolved discrepancies. The assessment was done as follows: if a ‘yes’ was marked, a point was

given, if ‘no’ or ‘can’t say’ were marked no points were given. When ‘does not apply’ was marked, no

points were given but the item was removed from the possible max score. If the final score was 80-100%

quality was marked as 3 (high quality or very low risk of bias), 65-80% as 2 (acceptable quality or low

risk of bias), 50-65% as 1 (low quality or high risk of bias), and 50% as 0 (unacceptable quality or very

high risk of bias) (see table 1).

  • 2.5 Data collection

The following data was extracted by JSMS and CTG from each article: 1. Authors; 2. Title; 3. Year; 4.

Quality; 5. Type of pain, acute defined as any pain that lasted less than 3 months or chronic, defined as

any pain of at least 3 months in duration; 6. Cause of pain, defined as procedural (diagnostic or surgical

procedures), oncological, labor, neuropathic, or other (e.g. experimental pain); 7. Summary measurements

(only for meta-analysis); 8. Intervention characteristics (delivery type, duration, timing, and music

selection); 9. Music type (how music is described and if music characteristics like tempo, harmony,

instrumentation or other were used); 10. General conclusions regarding the effect on pain, analgesic use or

sedative use by music, and how music type or characteristics affected this effect.

  • 2.6 Data analysis

Only descriptive synthesis of results was done. No quantitative analysis was performed, and results of this

type are presented as published by the original authors.



The full text of 128 articles was analyzed, of which 109 clinical trials were excluded (see supporting information on TableS1), so a total of 19 reviews were evaluated. Six were excluded for the following reasons: one included studies that only evaluated music in combination with other interventions (18), four did not include music listening studies (19-22), and one was published before 2004 (23). A final sample of 13 reviews (6, 24-35) was included for quality assessment and analysis (see figure 1).

Figure 1. PRISMA (36) flow diagram


  • 3.1 Quality assessment

A total of five studies (26, 31-34) (38.46%) were of unacceptable quality, one (35) (7.69%) was of acceptable quality, and seven (6, 24, 25, 27-29) (53.85%) were of high quality. Risk of selection bias was identified in nine (69.23%) reviews that did not list excluded studies (26-29, 31-35) and in five (38.46%) as selection of studies was not done by two people (25, 26, 31-33). Publication bias was identified in eight

(61.54%) that did not search for gray literature (6, 26, 27, 31-35), and in six in which this bias was not

evaluated (25, 26, 31-34). Attrition bias exists in four articles (30.77%) as two researchers did not perform

concurrent data extraction (26, 31-33). Risk for false result was identified in six studies (46.15%) due to

not considering article quality in the analysis (26, 28, 31, 32, 34, 35), and in four (30.77%) that did not

evaluated quality at all (26, 31, 32, 34). Risk for other biases were present in six reviews (46.15%) where

authors did not declare conflicts of interest (24, 26, 31-34) (see table 1).

Table 1. Quality assessment

  • 3.2 Study characteristics

The included reviews searched studies from 1898 (27) to January 2016 (30). All studies searched and

included randomized clinical trials (RCT) (6, 24-35), and some included other controlled trials (31, 34),

quasi-experimental (31, 32), and repeated measures studies (31). Six reviews included only research on

adult population (24, 26, 27, 32-34), five included both adult and pediatric population (6, 25, 28-30), and

two did not specify population characteristics (31, 35). Excluding the studies that did not specify

population, the number of included studies of music listening in adults ranged from 8 to 73. Three reviews

did not specify the number of allocated individuals per group, therefore the number of participants

exposed to music listening could not be determined (32, 34, 35). The total number of individuals that were

exposed to music listening ranged from 357 to 3095 (see table 2).

Music listening was compared with treatment as usual (6, 24-33, 35), silence (34), music combined with

other interventions (31-33, 35), active music therapy (29, 30) and other non-pharmacological interventions

(6, 25-27, 31, 33-35). All studies evaluated pain intensity or relief (6, 24-35) and some evaluated sedative

or analgesic use (24, 25, 27, 28, 31-33, 35) (see table 2).

Table 2. Characteristics of included studies

  • 3.3 Effect on pain relief

Six of the reviews performed a meta-analysis (24, 25, 27-30) and all of them had a high quality

assessment. The rest (n=7) only did qualitative summary of results, and of those only one was of high

quality (6), one was of acceptable quality (35), and the other five were of unacceptable quality (26, 31-34)

(see table 1).

Five of the six meta-analyses found that music had a significant effect on pain reduction compared to

controls (25, 27-30). Except for one study (28), all meta-analyses reported heterogeneity (25, 27, 29, 30)


the smallest being in oncologic pain (I = 65.07%) (29), and the highest in acute postoperative pain

(I 2 =92%) (27) (see table 3). Two reviews reported a meta-regression (25, 27), and one a sensitivity

analysis (29) but heterogeneity remained high. A sub-group analysis by Cepeda et al. found a significant effect of music on acute pain reduction (MD -0.56, CI 95% [-0.82, -0.29]) with an acceptable heterogeneity (I 2 = 34.9%) (25) (see table 3).

One meta-analysis evaluated different types of pain together, finding a small but significant effect (MD - 0.4, CI 95% [-0.7, -0.2]) (25). The only meta-analysis that did not find a significant effect evaluated pain


during colonoscopy (-0.46, CI 95% [-0.98, 0.07]) (24), contrary to this, Wang et al. found a significant effect on pain secondary to endoscopic procedures including Colonoscopy (WMD -1.53, CI 95% [-2.53, - 0.53]) (28). Tsai et al. and Bradt et al. evaluated oncologic pain, finding a significant effect (SMD -0.91, CI 95% [-1.46, -0.36] and SMD -0.656, CI 95% [-1.016, -0.295] respectively) (29, 30). Only one meta- analysis focused on postoperative pain, finding a significant effect (SMD -0.77, CI 95% [-0.99, -0.56]) (27) (see table 3).

Of the reviews describing qualitative synthesis only, two did not find that music had a significant effect on

pain on most of their included studies (6, 31). Two reviews evaluated acute and chronic pain; one included

14 studies and in 9 of them (64.29%) found a significant effect (26) and the other one included 4, finding a

significant effect in 3 (75%) (34). Nilsson et al. evaluated post-surgical pain finding a significant effect of

music in 13 of 22 studies (59%) (33), similarly another review found a significant effect in 15 of 18

studies (83.3%) (32) (see Table 3).

One review reported that music groups used significantly less morphine than controls (MD -0.48, CI 95%

[-0.85, -0.12], I 2 = 55.9%) (25), and another that they used lower doses of analgesics (SMD -0.37, CI 95%

[-0.54, -0.2], I 2 = 75%) (27). No differences in meperidine (WMD -5.27 CI 95% [-13.96, 3.41], I = 81.3%)



or midazolam use (WMD -0.55; CI (95%) [-1.21, 0.10]; I = 89.1%) (24), and no differences in analgesic

(WMD -8.44, CI 95% [-19.23, 2.34]) or sedative use (WMD -0.53 CI 95% [-1.39, 0.33]) in colonoscopy

procedures were identified (28). Among reviews reaching qualitative synthesis only, results were

contradictory (31, 33).

Table 3. Study results

  • 3.4 Characteristics of the intervention

Among the described results, four types of delivery mechanisms were identified (see table 3), headphones

(6, 26-28, 30-33), speakers (27, 28, 30, 33, 35), music pillow (27), live music (26, 30, 32, 34), and three

reviews did not specify any (24, 25, 29). One review exclusively searched studies using live music

preferred by the patient (34). The duration of the music intervention was described in six reviews (26, 27,

29, 30, 33, 35), ranging from 5 minutes to 4 hours (27, 30, 33). In three reviews, the music intervention

was described as matching that of the procedure being carried out (27, 30, 33). Eleven reviews specified

who selected the music (6, 24, 26, 27, 29-35). Regarding the timing of the music intervention on

procedural acute pain, music was delivered exclusively before, during, or after the procedure, or as a

combination of these (6, 27, 28, 32, 35).

Sub-group analyses found no significant differences when music was picked by patient or researcher (25,

27, 30). Hole et al. did sub-group analyses finding that the effect on pain was greater when music was

delivered before (SMD -1.28, CI 95% [-2.03, -0.54], I 2 =94%) than during (SMD -0.89, CI 95% [-1.2, -

0.57]), I 2 =92%), or after surgery (SMD -0.71, CI 95% [-1.03, -0.39], I 2 = 87%). Additionally, music had a

greater effect on postoperative pain of patients that were conscious throughout the procedure (SMD -1.05,


CI 95% [-1.45, -0.64], I =94%), with a smaller, but significant effect, when subjects were under general


anesthesia (SMD -0.49, CI 95% [-0.74, -0.25], I =25%) (27). No other sub-group analyses or conclusions

regarding the characteristics of the intervention were reported.

  • 3.5 Music type and music characteristics

Most of the reviews described the music used in their included studies using musical genre, song name, artist, or personal descriptions like “relaxing”, “soothing” or “easy listening” (24, 26-28, 30-33, 35). Three reviews failed to describe, in any form, the type of music used (6, 25, 34). Only six of the reviews included studies that described at least one music characteristic, but the number of patient groups exposed


to music described in terms of music characteristics was very small per review (see table 3) (26, 27, 30, 32, 33, 35). The only music characteristics described were a tempo of 60-80 bpm (26, 27, 30, 33) or under 120 bpm (35), music without lyrics or instrumental (26, 27, 32, 33), and music with a sustained melody (26). No analyses or conclusions were done regarding music type or music characteristics.



The majority of the included reviews in this study concluded that music has a significant effect on pain

intensity (25-30, 32-34), even when unacceptable quality reviews are excluded the majority are meta-

analyses and support the analgesic effect (25, 27-30). Despite that the effect of music on pain was

relatively small in some studies (see table 3), no adverse events were reported. Therefore results from

these reviews are strong enough to consider music a clinically significant complementary therapy to be

used for the management of pain (6, 24-35).

This study has some limitations, the most important being that it is an umbrella review, or review of

systematic reviews, which is a relatively new methodological approach for the analysis of summarized

evidence. Nonetheless, systematic reviews and meta-analyses have steadily increased in number (37) and

strategies to analyze these types of studies are required (15). As mentioned before, umbrella reviews lack

clear guidelines. However, to address this, established guidelines (PRISMA, AMSTAR) were used to

carry out portions of this review (15). Finally, only articles published in the last twelve years were


Pain is a complex clinical condition, and music is also a complex form of intervention, so the research of

both things can be highly complex. In such complexity, the high heterogeneity reported by the meta-

analyses is expected and mandates a detailed analysis (24, 25, 27, 29). When heterogeneity is high, results

must be analyzed with caution as some variables might be affecting the statistical effect of one or more

studies (38). These variables can be related to clinical environment, population, intervention, or

measurement methods (37-39). It is important to highlight that all studies reported heterogeneity using I 2 ,

this statistical approach is useful as it includes the proportion or number of studies in its calculation,

avoiding the sample size limitation of other formulae (40).

Conceptual homogeneity is expected when adequate, focused and specific research question and inclusion

criteria are used (37, 39). All meta-analysis use adequate and well formulated questions, but there are

some differences on how focused their questions were. Cepeda et al. searched for all types of pain, in

children and adults, of both sexes and didn’t specify clinical context (25). Hole et al. addressed their

research question to acute postoperative pain in adults (27) without specifying the type of surgery. Bradt et

al. and Tsai et al. focused on cancer pain in both children and adults (29, 30), but one included pain

secondary to procedures (except biopsies) (30). The other two evaluated pain related to endoscopic

procedures (24, 28), one did not specify type of endoscopic procedure or population (28), and Bechtold et

al. focused on adult patients undergoing colonoscopy (24). In consequence, it should be expected a

smaller heterogeneity in the study by Bechtold et al. and higher in Cepeda’s, but both were equally


heterogeneous (I = 84.7% and 84.9% respectively).

Heterogeneity can be addressed by means of a meta-regression, and sub-group or sensitivity analyses (37, 39). However, meta-regressions failed to identify a factor that could explain observed heterogeneity (25, 27), suggesting that the cause was a non-described variable. Cepeda et al. found that listening to music had a significant effect on acute pain (I 2 =34.9%) (25), and Hole et al. a significant effect on postoperative pain when music was delivered under general anesthesia (I 2 = 25%) (27). These sub-group results show


moderate heterogeneity (38) and constitute the only significant reduction from the high heterogeneity observed in all other analyses, suggesting that the grouping variable of acute pain might be of interest.

Results from this review show that the duration of music and timing of music is highly variable among RCT’s (see table 3). Only one review performed a sub-group analysis on the timing of music delivery finding a greater effect on pain when music was delivered before surgery than during, and the smallest

effect when delivered after, all three analyses with high heterogeneity (27). Sub-group analysis for music

selection found no differences when the patient or the investigator chose music, and the heterogeneity

remained high (25, 27, 30). A meta-regression included the duration of the intervention as a covariate,

failing to identify the source of heterogeneity (27). In most of the RCT’s music was delivered by

headphones (see table 3), so it is highly unlikely that this is the reason for the observed heterogeneity.

These findings prove that music as an intervention is highly variable and complex, therefore replicability

would be difficult. It is important to highlight that no differences on music selection were identified in this

review. In consequence, music selected by the researcher can be as effective as the one selected by the

patient. For the sake of research, music selected by researcher will allow the use of highly controlled

interventions so specific conclusions related to the intervention can be reached. Nonetheless, selecting

music might be extremely difficult due to music’s complexity and variety.

Music listening is considered a passive music intervention, and depending on the selection process can be

considered a music therapy or music medicine intervention. If a certified music therapist is involved in the

process of selecting the song or songs, the intervention should be considered music therapy, if no music

therapist was involved, it is music medicine (4-6). It is hard to define what a certified music therapist is,

what level of formation they should have, or more importantly, if the formation is appropriate enough for

music selection for a specific goal on a complex condition like pain. The complexity is larger for music

medicine, where no music therapist is involved.

Robb et al. published in 2011 reporting standards for music interventions (41). One of the main points in

this paper is the appropriate description of the music intervention (Item 4B), but it does not provide an

objective language for this. It suggests that proper reference to the music sheet or recording used is the

most adequate option, nonetheless those without music knowledge won’t be able to replicate, describe or

understand the intervention. Proper analysis of music description and reporting was an appropriate step on

music based interventions research, especially for music listening interventions.

As shown in Table 3, music type was described mostly in terms of genre or other subjective characteristics

(e.g. “relaxing music”), and it was unusual for two studies to use the same type of music. Describing

music in in these terms lack validity and universal interpretation (42). This supports the need of a more

objective approach to describe music.

Music theory is a discipline dedicated to the study of music and its components. According to it, music is

defined as the organized combination of sound, which can be described in terms of musical organization

(harmony or melody), metrical organization (rhythm and its components), and sound related properties

(volume and pitch) (43, 44). For example, all melodies and harmonies are constructed under a scale or

mode that can be classified as major or minor (43, 45), and all rhythms have a defined tempo/pulse (46). In consequence, two songs of the same genre can have very different melody and tempo, and two songs of

different genres can have similar melodies and tempo. Concepts used by music theorists are objective and allow replication; therefore it is an appropriate language to be incorporated in the conduction and reporting of music related research.


Many authors have suggested that these characteristics are crucial for accomplishing specific therapeutic goals (4, 14) and have highlighted the need for controlled musical interventions (4, 9, 47). This is supported by the finding that neuronal networks activated by three pieces of Guquin music were different on male subjects (10). Different cortical areas have been related to pain modulation (19), and music seems to activate these structures (7, 11-13), supporting music’s pain modulatory effect.

These results show that music characteristics (like tempo, harmony and others) are not used in the

selection of musical interventions for pain, nor are they described by authors of clinical trials. Although

reporting standards for music interventions exist (41), none of the reviews acknowledged their existence,

nor did they incorporate them into the quality assessment process. Therefore, no analyses or conclusions

can be reached regarding music characteristics. Complexity of both, music and pain, explains the results

from this review, and proves that the research of music listening has come a long way, but there is still

much to do in the future.



The low risk of bias in the included meta-analyses, the fact that the effect of music on pain was significant

despite multiple analyses, and that no secondary effects were described, evidence from these reviews

support its use as complementary therapy for acute (surgical and procedural) and cancer pain relief. Due to

high heterogeneity it is unclear the specific pathologies or clinical context where it should be used.

Researchers are not describing music objectively; neither are they taking into account music

characteristics like musical mode, tempo, consonance, and others when choosing the musical intervention.

This review proves that the research of music listening interventions has come a long way, but

replicability of interventions is still lacking. Problems with replicability may be secondary to how

researchers are reporting and describing music, which may improve by incorporating the language and

concepts of music theory.

ACKNOWLEDGEMENTS: The authors thank Dr. Ivan Felipe Pradilla Andrade for his support in

proofreading of the manuscript.

Research Funding: No funding was received for this paper.

Conflict of Interest: No conflict of interest exist.

Data Statement: Data is presented through the text’s tables, figures and supplemental data, but if more

information is required please contact the corresponding author.


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Figure 1. PRISMA (36) flow diagram

Records identified through

database searching

(n =


Records after duplicates removed

(n = 3815)

Records screened

(n = 3815) Full-text articles assessed for eligibility (n = 128)
(n = 3815)
Full-text articles assessed
for eligibility
(n = 128)

Studies excluded by title

or abstract for not being

systematic reviews or


(n = 3687)

Full-text articles excluded,

with reasons

(n =


109 clinical trials or other

1 included studies that

mixed music and other

form of therapy

Studies included in

qualitative synthesis

(n = 13)

4 didn’t include music

listening studies

1 published on 2000


Table 1. Quality assessment using RSL-SIGN

Authors Year 1 2 3 4 5 6 7 8 9 10 11 12 Score Max
12 Score Max

Yinger et al.


Wang et al.


Bechtold et al.


Tsai et al.


Dunn K.


Hole et al.


Engwall et al.


Cole et al.


Cepeda et al.


Silverman et al.


Subothini et al.


Bradt et al.


Nilsson U.


A CCEPTED MANUSCRIPT Table 1. Quality assessment using RSL-SIGN Authors Year 1 2 3 4 5








































  • No/Can't say

  • Does not apply

  • Yes

Table 2. Characteristics of included studies









Type of Studies











- 2006





Usual care

Randomized controlled

Pain intensity, sedative

Pain measurement tool not





use, midazolam mean

specified; High heterogeneity


doses, meperidine mean





- Oct

Patients with

43 a

1533 a


Usual care, other

Randomized controlled

Pain intensity, pain

Too many outcomes and



acute, chronic,


pharmacological or


relief, analgesic use

clinical settings evaluated



non pharmacological

together; High heterogeneity

cancer, or




Cole 2014


Adults on an in-




Usual care, patient

Randomized controlled

Pain intensity

Outcomes not previously


patient setting


teaching, relaxation,


established; Results presented




as summary of studies


Dunn K


Patients on

10 b

904 b


Usual care, music +

Randomized controlled

Pain intensity, analgesic

Population and comparison not




other, resting,

trials, controlled trials,


pre-defined; No clear inclusion


relaxation, noise


criteria; Search limited only to



repeated measures

the US and UK; Studies only summarized

Hole 2015

1898- Oct





Usual care, other non

Randomized controlled

Pain intensity, analgesic

High heterogeneity; Forrest

1, 2013






plot for specific analysis not


surgery except






– Jan





Usual care, other non

Randomized controlled

Pain intensity, analgesic

Only articles in English were







use, sedative use

included; No specific



interventions, music +

qualitative analysis done


other, white noise


Until Apr

Patients with

5 b


b c


Usual care, pink noise,

Randomized controlled

Pain intensity, analgesic

Only articles in English and in


17, 2015

Osteoartritis or


music + vibratory



peer reviewed; Studies only




stimuli, vibratory

summarized; Intervention






Medical in and





Pink noise, silence

Randomized controlled

Pain intensity

allocation not specified Only articles in English; Pain




trials, pre-posttest

measurement tool not specified


live music

clinical trials

Tsai 2014

2002 – Dec

Cancer patients

16 a




Usual care, active

Randomized controlled

Pain intensity, pain

Funnel plot not shown; Small



music involvement



number of studies included for



pain meta-analysis.


Bradt 2016

1950 – Jan

Cancer patients

32 a

1928 a


Usual care, 60 cycle

Randomized controlled

Pain intensity

Meta-analysis included studies


not undergoing


hum listening, music


that evaluated active music


biopsy or


therapy, noise control,




guided imagery, resting



  • 1998 Adult patients




Usual care, jaw

Randomized controlled

Pain intensity, pain

Only articles in English were


  • 2007 on



relaxation, music +

trials, quasi-experimental

distress, analgesic use

included; Nine of the included



other intervention,

studies were done by 2 authors;


headphones with no

Three studies were secondary


music, resting, guided

analysis of another one



  • 1975 Adults or

36 a

1662 a


Usual care, guided

Randomized controlled

Pain intensity

Only articles in English were


  • 2014 children (3 year



imagery, headphones



or older)


with no music,


relaxing suggestion,

medical procedures

massage, audio book

Wang 2014

Until Jul


19 a

993 a


Usual care

Randomized controlled

Pain intensity, analgesic

No forest plots shown; No

  • 2013 undergoing





heterogeneity evaluation




  • a. Search included studies with pediatric population or didn't specified age in their results so number of studies and patients were adjusted to only adults

  • b. Population characteristics weren't specified so it is not known if pediatric population was included

  • c. Number of subjects allocated to music intervention wasn't specified for any study so the total of the sample per study was used

Table 3. Study results



Type of

Music type

Music delivery


Quantitative results (meta-analysis only)


General conclusions





Acute pain

Relaxing Enya (n=1); Not specified

Duration not specified.

Selected by

Pain reduction: SMD (random) = -0.46; CI (95%)

No significant differences for pain scores,



(n=2); Turkish classical (n=1).

patient (n=


[-0.98, 0.07]; I =84.7%


midazolam or meperidine dose changes were


Timing was prior or

2); Selected

Midazolam doses: WMD (random) = -0.55; CI


during procedure (not



(95%) [-1.21, 0.10]; I = 89.1%




Meperidine doses: WMD (random) = -5.27; CI

All meta-analysis had very high heterogeneity (>




(95%) [-13.96, 3.41]; I = 81.3%


80%) .


Characteristics of music like tempo, harmony, or other weren’t described or used for analysis.

Characteristics of intervention delivery weren’t specified or used for analysis.

No conclusions on music type or music election

were reached.



Not specified

Not specified


Pain reduction all studies: MD-0.4 (0-10), CI

Music favors pain and morphine reduction.





(95%) [-0.7, -0.2)], I = 84.9%




Pain reduction in adults: MD (random)


Heterogeneity was very high in all meta-analysis

l, labor)



CI (95%) [-0.09, 0.07], I = 85.3%


except for acute pain, with the effect favoring

pain, and


Acute pain: MD (random)


music in almost all cases.




-0.56, CI (95%) [-0.82, -0.29], I = 34.9%



Procedural pain: MD (random) 0.1, CI (95%)

Meta-regression didn’t identified cause for high


[0.02, 0.19), I 2 =86.4%




Selected by patient: MD (random) 0.2, CI (95%)

[0.05, 0.35], I 2 = 82.3%


Music type and delivery weren’t specified neither

Selected by investigator: MD (random)


used for analysis.

CI (95%) [-0.17, -0.01], I 2 =88%


Overall risk of having 50% of pain relief: RR

Music characteristics (e.g. tempo, harmony, or

(fixed) 1.7 favoring music, CI (95%) [1.21, 2.37],

other) weren’t described or used for analysis.

I 2 = 0.0% Morphine requirements:


MD (random)

-0.48, CI (95%) [-0.85, -0.12],

No difference was identified between music

I 2 = 55.9%

selected by investigator or patient.

Cole 2014


Not specified (n=6); Varied patient

Delivery type:


Only qualitative analysis was done.


A significant reduction of pain was found on 9


selected (n=1); Low pitched, slow

Via headphones (n=


studies of 14.


tempo of 60-80 bpm with no lyrics

6); Speakers (n=2 );



of three types (n=1); Slow, soft

Not specified (n=4);

Selected by

Music characteristics where described in some of


music with no lyrics (n=1); Slow of

Live music (n=1)


the included studies but analysis of this wasn’t


60-80 bpm and soft music (n=1);





Slow of 60-80 bpm and soft of 50-

30m (n=6)

Selected by


60 dB music (n=1); Slow of 60-80

45m (n=2)


Music delivery characteristics where also specified


bpm, no lyrics nor percussion, with

15m (n=1)


but weren’t used for analysis.


sustains melody (n=1); Live music



20m(n=2); Not

No conclusions on music type, music


specified (n=1)

characteristics, or delivery of music were reached.


Dunn K


Not specified (n=9); Soothing and

Delivery type:

Selected by

Only qualitative analysis was done.

Qualitative description of results with very poor



stimulating music (n=1); Soothing

Via headphones (n=2)




music (n=1)

Not specified (n=9)



Duration not specified

In the findings section mentions 11 studies were


Selected by

included but only 10 described in the table of





Half of the studies found that music reduced pain and analgesic need postoperatively

Hole 2015


Not described (n=28); Classical

Delivery type:

Selected by

Overall pain reduction: SMD -0.77, CI(95%) [-

Subgroup analysis showed that type of control


(n=7); Sedative (n=3); Relaxing

Headphones, music



0.99, -0.56), I = 90%


didn’t affect music effect


(n=10); Soothing (n=2); Turkish

pillow or speaker (not


Back calculation to VAS 100 mm showed an


classical (n=2); Easy listening


average reduction of 23 mm by music

Univariate meta-regression for all variables didn’t

(n=1); Watermark by Enya (n=1);


Selected by

Pain measured before 4 h: SMD -0.79, CI(95%)

show significant differences.

Dream flight 2 (n=1); Slow and

Duration of procedure



[-1.06, -0.52], I = 90%


rhythmic (n=1); Slow and soft

(n=41); Duration


Pain measured 4h after surgery: SMD -0.76,

No significant difference was found when patients

(n=1); Soft piano (n=1); Musicure

procedure + 60m


CI(95%) [-1.19, -0.33], I = 90%

selected the music against when the investigator

(n=3); Instrumental (n=3); Soft

(n=1); Until patient

Music elected by patient: SMD -0.86, CI(5%) [-


instrumental (n=1); Baroque (n=1);

requested (n=1); Until


1.14, -0.57], I =90%


Pan flute music (n=1); 60-80 bpm

discharge (n=1);

Music elected by researcher: SMD -0.70,

High heterogeneity (I 2 = 75-92%) in main analysis

tempo (n=1); Soft music (n=1);



CI(95%) [-1.01, -0.39], I =88%

even after meta-regression.

Chinese classical (n=1); Spanish

ambulation (n=1); 2m

Music delivered preoperatively: SMD -1.28,

Guitar (n=1); Easy listening (n=1);

and whenever the


CI(95%) [-2.03, -0.54], I =94%

Acceptable heterogeneity was found in the effect of

Prescriptive (n=1)

patient choose (n=1);

Music delivered intraoperatively: SMD -0.89,

music on pain under general anesthesia, and on


20m (n=4); 30m


CI(95%) [-1.2, -0.57], I =92%

analgesia use when music was given after the

(n=13); 40m (n=1);

Music delivered postoperatively: SMD -0.71,

procedure. Both cases music had a significant

45m (n=1); 60m

CI(95%) [-1.03, -0.39], I 2 = 87%

effect on both outcomes. The smallest

(n=2); 10m (n=1); 4h

Music delivered when conscious: SMD -1.05,

heterogeneity was found in the effect of music pre-

(n=1) Not specified

CI(95%) [-1.45, -0.64], I 2 =94%

operatively on analgesia use.


Music delivered under general anesthesia: SMD -


0.49, CI(95%) [-0.74, -0.25], I 2 =25%

Subgroup analysis showed that music used

During procedure

Overall analgesic use: SMD -0.37, CI(95%) [-

preoperatively, and with the patient conscious has a

(n=33); After

0.54, -0.2], I 2 = 75%


greater effect.

procedure (n=23);

Analgesic use when music was given before

Before procedure

procedure: SMD -0.43, CI(95%) [-0.67, -0.20],

Characteristics of music like tempo, harmony, or

(n=1); Before, during

I 2 = 4%

other weren’t used for analysis.

and after (n=2); Before

Analgesic use when music was given during

and during (n=9);

procedure: SMD -0.41, CI(95%) [-0.70, -0.12],

Other characteristics of music delivery like, the use

Before and after (n=3)

I 2 = 84%

of headphones, or time of intervention weren’t


Analgesic use when music was given after


procedure: SMD -0.27, CI(95%) [-0.45, -0.09],

I 2 = 40%

No conclusions on music type, music


Acute pain

Not specified (n=10); Classical,

Delivery type:

Selected by

Only qualitative analysis was done.

characteristics, or delivery of music were reached. From 22 studies, 13 (59%) music had a significant



environmental, new age,

Headphones (n=39)


effect on pain reduction.


country/western, easy listening

Speaker (n=1)


(n=1); Soothing music (n=1); New age (n=5); Classical, jazz,

Not specified (n=2)

Selected by

Only 15 of the included studies evaluated analgesic use finding that 7 (47%) reported a significant

country/western, new age, easy






listening, other (n=1); Classical with nature sounds (n=1); Slow, quiet and instrumental (n=1); Synthesizer, harp, piano, orchestral

Not specified (n=4); 30m (n=9); Duration of procedure (n=7); Duration of procedure


Characteristics of music like tempo (only one included study specified music of 60-80 bpm

or slow jazz (n=4); Pan flute (n=1);

+ two other (n=1);

tempo), harmony, or other weren’t described or

Classical (n=1); Piano (n=2);

10m (n=1); 40m

used for analysis.

Eastern, western, easy listening,

(n=2); 20m (n=6);

Chinese pop (n=1); Pop, jazz,

60m (n=5); 15m

Author describes soothing as a tempo of 60-80

classical, new age (n=1); Classical,

(n=2); 15m pre-

bpm, therefore only one study had this

gagaku, noh, enka (n=1); Lullaby

procedure + duration


and relaxing (n=1); Classical,

of procedure (n=1); 4h

popular, contemporary, Chinese

(n=1); 117m (n=1); 2h

None of the musical interventions were developed

Conclusions on how music dosage characteristics

(n=1); Soft classical (n=1); Easy


for the treatment, therefore it can’t be concluded if

listening, classical, or jazz (n=1); Mozart and ocean music (n=1); Slow rhythmic Chinese or Western (n=1); Relaxing music (n=1); Chinse or Western (n=1); Relaxing, slow rhythm and sedative (n=1);

a specific designed music could have a better effect.

(e.g. volume, duration, other) affects the music effect are required.

Country/western, instrumental, new

age (n=1).


Chronic non

Mozart’s Classical (n=1)


Selected by

Only qualitative analysis was done.

Small number of studies, insufficient to reach



Not specified (n=4)


conclusions on these diseases.

pain and

Bach’s Classical (n=1)

Speaker (n=1)

(n=3); by

acute pain

Duration: 20m (n=1);


No conclusions on music type, characteristics, or


Not specified (n=1)

60m (n=1); Not


delivery were reached.


specified (n=3)



Pleasant and <120 bpm (n=1)




Before and during



Salsa and classical (n=1)

procedure (n=1)


Acute pain

Not specified (n=8)


Selected by

Only qualitative analysis was done.

Only four studies evaluated pain and 3 of them



Live music (n=8)


found a significant effect.

and chronic



Duration not specified

Other characteristics of music like harmony, tempo


or other weren’t described or used for analysis.


Timing not specified


Other characteristics of the intervention like

delivery and duration weren’t used for analysis.

Tsai 2014


Not specified (n=16)


Selected by

Overall pain reduction:

The overall effect favored music significantly for


Not specified (n=16);


SMD -0.656, CI(95%) [-1.016, -0.295], I 2 =

pain reduction after meta-analysis, it included a




study on children and one with music therapy.


Duration: Not

Selected by

specified (n=6);


Heterogeneity was high and didn’t change with

30m(n=3); 15m (n=2);


sensitivity analysis.

45m (n=2); 20m

(n=2); 60m (n=1)

Characteristics of music like harmony, tempo or other weren’t described or used for analysis.

No conclusions on music type, delivery or election were done.




Relaxing music from classical, jazz,


Selected by

Overall pain reduction:

Overall effect on pain reduction included all forms



folk, rock, country and western,

Headphones (n=14);


SMD -0.91, CI(95%) [-1.46, -0.36], I 2 =88%.

of music intervention and populations, despite this

pain and

easy listening, or new age (n=1);

Live music (n=6); Not


a significant effect but a very high heterogeneity

acute pain

Classical, easy listening,

specified (n=8);

Pain reduction on patient selected music:

was found.


inspirational or new age (n=1); Not

Speaker (n=2)

Selected by


SMD -1.06, CI (95% [-1.93, -0.2], I =91%


specified (n=9); New age, nature,


Three of the excluded studies from meta-analysis

film soundtracks, Celtic melodies,



Pain reduction on researcher selected music (only

found that music reduced significantly pain

or classical music (n=1); Live

45m (n=5); 4h (n=1);



saxophone music (n=1); Chinese

15m (n=2);



SMD -0.56, CI (95%) [-1.34, 0.15], I =75%

classical music (n=1); Slow-paced,

30m(n=11); 60m


When a subgroup analysis of music selection was

melodic music at low volume with

(n=2); 20m (n=2); 5m


done, a bigger effect with no significant difference

consistent tempo and dynamics of

(n=2); duration of

was found when music was selected by the patient

60-80 bpm average chosen from

procedure (n=3); Not

on pain.

mandarin, mandarin pop, taiwanese,

specified (n=3);

western or classical music(n=1); Relaxing music from classical, harp, general instrumental, nature

One study that described music as slow (60-80 bpm) and with controlled low volume (not specified) didn’t evaluate its effect on pain.

sounds, country, gospel or jazz (n=1); Live guitar music (n=3); New age (n=1); Sedative (60- 80bpm) without lyrics, with sustained melodies, controlled

One study described music as tempo 60-80 bpm, without lyrics and controlled volume and pitch that evaluated pain. This study found an effect favoring music.

volumes and pitch between Taiwanese or Buddhist music (n=1); Chinese classical (n=1); CM5-element music (n=1); Vietnamese or children’s music

Most studies didn’t described other characteristics of music like harmony, tempo or other weren’t described or used for analysis.

(n=1); Live music (no instrument specified) (n=2); Vivaldi’s Four

Other characteristics of the intervention like delivery weren’t used for analysis.

Seasons (classical) (n=1); Rock and

roll, big band, country, classical, easy listening, Spanish or religious music (n=1); Sacred, Chinese classical, western classical, or yoga music (n=1); Chinese relaxation music, classical folk music, or religious music (n=1).

No conclusions on music type, delivery strategy or characteristics of music were done.


Acute pain

Piano, harp, synthesizer, orchestral,


Selected by

Only qualitative analysis was done


From all studies only three studies showed no



or slow jazz without lyrics (n=5);

Live (n=1);

the patient

significant differences between music and control


Soft classical (n=1); Relaxing and

Headphones (n=16);


groups on pain, the rest found a significant effect of

calming accompanied by sound

Not specified (n=1)

music on postoperative pain.

waves (n=1); Soft instrumental or

Selected by

new age synthesizer (n=2); Peaceful



Half studies found a significant difference on

pan flute music (n=1); Piano music

Postoperative (n=13);


analgesic use.

(n=1); Classical, jazz, light rock,

Intra and postoperative


country, rock and roll, easy


Several studies reported manipulating the

listening, gospel, country, and rock and roll (n=1); Western classical music, gagaku, noh songs or enka

Intraoperative (n=1); Not specified (n=1)

environment (for better control) and giving instructions on music use.

(n=1); Easy listening, classical, and

Duration not specified.


jazz (n=1); Synthesizer, harp, piano,

orchestra, slow jazz, or flute (n=1); Chinese and western music (n=1); Mozart and ocean music (n=1); Slow and soft melodies played on a harp (n=1)

Characteristics of music like tempo, harmony, or other weren’t described or used for analysis.

Characteristics of intervention delivery weren’t used for analysis.

Analysis on election of music wasn’t done

No definite conclusions on music type, music

characteristics, or delivery of music were reached.


Acute pain

Not specified

Duration not specified

Selected by

Only qualitative analysis was done.

Only 25 studies analyzed the effect of music





listening on pain perception on adults, finding that


Not specified (n=39);


only 11 (38%) favored music.

Headphones (n=3)

Selected by



Characteristics of music like tempo, harmony, or

Before, during and


other weren’t described or used for analysis.

after procedure (n=6);


During procedure


Characteristics of the intervention like delivery and

(n=17); Before and


duration weren’t specified or used for analysis.

during procedure

(N=15); After

Analysis on election of music wasn’t done.

procedure (n=2);

During and after

No conclusions on music type, characteristics, or

procedure (n=2)

delivery strategies was reached.


Acute pain

Not specified (n=10); Indian classic



Overall pain reduction:

The overall effect on endoscopic procedural pain



(n=1); sedative music (n= 2);

During procedure


WMD -1.53, CI(95%) [-2.53, -0.53]

reduction favored the music group.


Turkish classical (n=1); Easy

(n=15); Before

listening (n=1); Classical (n=2);

procedure (n=2);

Reduction of pain on Colposcopy procedures:

Sub-group analysis found that the effect didn’t

Relaxation music (n=2); Slow

Before and During

WMD -3.30, CI(95%) [-13.49, 6.89]

favored music on Colposcopy procedures.

rhythm (n=1); New wave (n=1)

procedure (n=4)


Analgesic use in Colonoscopy:

No significant effect on analgesic or sedative use


Duration not specified

WMD -8.44, CI(95%) [-19.23, 2.34]

was identified.

Delivery: Headphones

Sedative use:

Heterogeneity wasn’t reported.

(not specified);

WMD -0.53 CI (95%) [-1.39, 0.33]

Speaker (not specified)

Characteristics of music like tempo, harmony, or other weren’t described or used for analysis.

Characteristics of intervention delivery weren’t specified or used for analysis.

Authors recognized that music tempo, harmony and rhythm could have an impact on the effects on pain despite no analysis on this was done.

No certain conclusion on music type, music characteristics, delivery of music or music election were reached.

n= Number of intervention groups that were exposed; m= minutes; h=hours; WMD= weighted mean differences; SMD= standardized mean difference; MD= mean difference; CI= confidence interval.



Until now, no authors have analyzed the specific aspects behind music

listening as an intervention. There is no knowledge on the ideal ways to use this strategy, and despite the

existence of guidelines, this study proves it. This review offers analyses on what is needed for advancing on music for pain relief.